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IPT: MS > More Block 2 > Flashcards

More Block 2 Flashcards

1
Q

What kind of disease is SLE and who does it occur most often in?

A

Chronic autoimmune disease

Women, teenage to early 50s, more common in AA or hispanics

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2
Q

What causes SLE?

A

Genetic factors (HLA-DR2/3) and environmental factors (Ebstein-Barr virus, hydrazine from smoking, estrogen, rx, UV light)

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3
Q

Presentation of SLE?

A

Multi organ involvement + SLE flare

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4
Q

How is lupus nephritis classified?

A

Class III = focal (<50% glomeruli involvement)

Class IV = diffuse (≥50% glomeruli involvement)

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5
Q

What can antiphospholipid syndrome cause?

A

Increased risk of VTE, thrombosis, and fetal loss

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6
Q

How is antiphospholipid syndrome diagnosed?

A

At least 1 clinical:

  • thrombosis
  • 1+ unexplained death of fetus
  • 3+ unexplained miscarriages before 10th week of gestation

At least 1 lab criteria, intermediate or high titers of:

  • IgG or IgM
  • Lupus anticoagulant antibodies
  • Anti Beta-2 glycoprotein I antibodies

All lab tests involve 2 tests 3 months apart

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7
Q

What lab tests are involved for SLE?

A

ANA and APA

CBC w/ differential

SCr

Urinalysis w/ microscopy

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8
Q

Nonpharmacologic therapy for SLE?

A
  • smoking cessation
  • sun protection
  • pneumococcal, influenza, hep B (just dont give live to pts receiving immunotherapy)
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9
Q

Uses of ASA? Considerations?

A

Low dose for antiphospholipid syndrome

Reye’s syndrome

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10
Q

Uses of Steroids? Considerations?

A

Locally for skin manifestation (low potency for areas like the face)

If given systemically, use calcium/vit.d/bisphosphonates for osteoporosis prevention

Caution with live vaccines

Increased % of infections

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11
Q

Use of Hydroxychloroquine? Considerations?

A

All pt with lupus (can reduce clotting)

Risk include retinal toxicity

Dont exceed 5mg/kg/day or 400mg daily

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12
Q

Use of methotrexate? Considerations?

A

Given once weekly, max of 20mg/week

Dose adjustments for renal/hepatic impairment

AVOID in pregnancy

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13
Q

Use of azathioprine? Consideration?

A

Used as MAINTENANCE therapy for nephritis only

Lower dose if TPMT deficient

DDI w/ allopurinol and febuxostat

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14
Q

Use of mycophenolate? Consideration?

A

Used as both MAINTENANCE + INDUCTION therapy for nephritis

AVOID in pregnancy

Highly protein bound

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15
Q

Use of cyclophosphamide? Consideration?

A

Used as INDUCTION therapy only for nephritis

AVOID in pregnancy

Infertility issue in women and men

Can cause hemorrhagic cystitis and bladder cancer

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16
Q

Belimumab MOA?

A

Recombinant antibody that promotes B cell apoptosis by binding to BLyS

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17
Q

Use of Belimumab? Consideration?

A

ADJUNCT therapy with positive SLE

Dont give with live vaccines within 30 days, dont give with other biologics or cyclophosphamide

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18
Q

Use of Rituximab? Consideration?

A

Salvage therapy for both SLE and lupus nephritis

Premedicate to prevent infusion and hypersensitivity reactions

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19
Q

Primary prophylaxis for antiphospholipid syndrome? Secondary prophylaxis? Duration?

A

HoCQ or low dose ASA

With DEFINITE APS and first event, treat with warfarin

If first VTE event, low risk for APS and known factors, 3-6 months

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20
Q

What patient population is affected by drug-induced lupus?

A

Caucasian older patients

Except in minocycline, then its younger females patients

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21
Q

How is drug-induced lupus presented and what are some lab findings?

A

Systemic symptoms

Positive ANA and histone antibodies

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22
Q

What are the common drugs to cause drug-induced lupus?

A

Procainamide
Isoniazid
Hydralazine

Minocycline
Methyldopa

Quinidine
TNF alpha inhibitors (etanercept, infliximab, and adalimumab)

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23
Q

What kind of symptoms can procainamide cause? RF?

A

Usually MSK sx

RF = slow acetylators

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24
Q

What kind of symptoms can hydralazine cause? RF?

A

Usually MSK sx with cases of glomerulonephritis

RF = >200mg/day or cumulative dose of 100g

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25
Q

What kind of symptoms can TNF alpha inhibitors cause? RF?

A

Usually MSK or cutaneous symptoms

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26
Q

What kind of symptoms can minocycline? RF?

A

Usually MSK or hepatic symptoms

RF = younger patients

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27
Q

What are some medications that should be held before surgery?

A

Antithrombotic therapy

Cardiac meds

Diabetic meds

Herbal meds

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28
Q

What are the high thromboembolic risk patients?

A

Mech. mitral valve or valve prosthesis

CHADSVASC score 7-9

Stroke or TIA within 3 months

Rheumatic valvular heart disease

VTE within 3 months

Severe thrombophilia

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29
Q

What are the moderate thromboembolic risk patients?

A

Aortic valve replacement and one of the following: A. fib, diabetes, CHF, >75yo

CHADSVASC score 4-6

VTE within 3-12 months

Non severe thrombophilia

Active cancer

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30
Q

What are the low thromboembolic risk patients?

A

Aortic valve replacement w/o RF

CHADSVASC score of 0-3

VTE >12 months ago with no RF

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31
Q

What operations are considered high surgical bleed risk?

A

Orthopedic

Low = dental, endoscopy w/o biopsy, dermatologic, cataract surgery

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32
Q

When do you d/c warfarin before surgery?

A

5 days prior

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33
Q

When do you check INR if pt was on warfarin before surgery? What can you do if elevated?

A

1 day prior

Give low dose PO vit. K for INR >1.5

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34
Q

When can you resume warfarin after surgery?

A

12-24 hrs after surgery

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35
Q

If pt is going through a low bleed risk procedure, when can you stop warfarin?

A

2-3 days prior (or give warfarin as is with prohemostatic agent)

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36
Q

What is the advantage of bridging with LMWH or heparin products?

A

You can stop 4-6 hours (UFH) or 24hrs (LMWH) before surgery vs 5 days prior with warfarin alone

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37
Q

When can you continue LMWH therapy after high bleed risk surgery?

A

2-3 days after surgery

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38
Q

How long should you hold theses DOACs in minor surgery (good renal function)?

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

A

All 1 day prior to surgery

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39
Q

How long should you hold theses DOACs in major surgery (good renal function)?

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

A

All 2 days prior to surgery, except dabigatran is 2-4 days prior

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40
Q

How long should you hold theses DOACs in minor surgery (CrCl<50)?

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

A

Dabigatran = at least 2 days prior

Rivaroxaban = 1-2 days

Apixaban = 1-2 days

Edoxaban = n/a

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41
Q

How long should you hold theses DOACs in major surgery (CrCl<50)?

Dabigatran
Rivaroxaban
Apixaban
Edoxaban

A

Dabigatran = 4 days

Rivaroxaban = 3-4 days

Apixaban = 3-4 days

Edoxaban = n/a

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42
Q

When should someone with aspirin continue using their dose when undergoing some operation?

A

If using for secondary CV disease prevention or on low bleed risk surgery

Moderate to high risk for CV and require non-cardiac surgery

Undergoing CABG. If they are on dual antiplatelet therapy, stop clopidogrel/prasugrel 5 days prior

43
Q

When should someone with aspirin stop taking their dose when undergoing some operation?

A

If they are low risk for CV event, stop it 7-10 days prior

44
Q

When should surgery be deferred if they are on aspirin?

A

If they have a coronary stent on dual antiplatelet therapy (at least 6 wks on bare metal stent or 6 months after drug eluting)

45
Q

When should someone on P2Y12 inhibitors hold their dose before surgery?Cilostazol?

A

5-10 days prior for clopidogrel or prasugrel

5 days prior for ticagrelor

2-3 days prior for cilostazol

46
Q

What is virchow’s triad?

A

Hypercoagulability

Blood flow stasis

Vessel wall injury

47
Q

Which surgeries should include VTE prophylaxis?

A

Major orthopedic surgery or anyone with fracture of pelvis, hip, or long bone

48
Q

Those with total hip or knee arthroplasty should receive which VTE prophylaxis?

A

Receive aspirin or anticoagulant therapy

DOACs>LMWH>Warfarin when anticoagulation is needed

LMWH>UFH

49
Q

Those with hip fracture repair should receive which VTE prophylaxis?

A

LMWH or UFH

50
Q

VTE prophylaxis, Rivaroxaban dosing?

A

10mg QD within 6-10 hrs after surgery for 10-14 days (maybe up to 35 days)

Avoid if CrCl<30

51
Q

VTE prophylaxis, Apixaban dosing?

A

2.5mg BID within 12-24hrs after surgery for 10-14 days (maybe up to 35 days)

52
Q

VTE prophylaxis, Dabigatran dosing?

A

110mg once within 1-4hrs after surgery for 10-14 days. MD = 220 QD (maybe up to 35 days)

Avoid if CrCl<30

53
Q

VTE prophylaxis, ASA dosing?

A

After 5 days of anticoagulation, initiate 81mg QD

54
Q

VTE prophylaxis, LMWH (Lovenox) dosing?

A

40mg QD or 30mg q12hrs. You can start 12hrs after surgery for 10-14 days (maybe up to 35 days)

Renal dosing = 30mg QD

55
Q

VTE prophylaxis, UFH dosing?

A

5000u every 8-12hrs within 12 hrs of surgery for 10-14 days (maybe up to 35 days)

56
Q

VTE prophylaxis, Fondaparinux dosing?

A

≥50kg: 2.5 QD within 6-8hrs after surgery for 10-14 days (maybe up to 35 days)

Avoid if CrCl<30

57
Q

RF for infection prevention?

A

Diabetics, Malnutrition, inflammatory arthritis, MRSA colonization, skin infection/chronic UTIs

58
Q

When are prophylactic ABx given and d/c after surgery? Which ABx are they?

A

Given 1 hr prior

D/c within 24 hrs afterwards (unless cardiac, then 48hrs)

Cefazolin 2g (3g if ≥120kg)

or clinda or vanco if allergic to B-lactam

59
Q

What is rhabdomyolysis?

A

Muscle pain and/or weakness with elevations of CK >10ULN with evidence of AKI

A kind of myopathy

60
Q

What is creatine kinase?

A

Intracellular enzyme that is released due to cell membrane damage

Testing for them is highly sensitive, but is not very specific

61
Q

What is a general CK range what can cause it to rise?

A

<300IU/L in adults

Thyroid, muscular dystrophy, dehydration, MI

62
Q

Normal serum levels of Myoglobin? What are some symptoms of high levels?

A

> 85ng/mL suggest muscle injury

Tea-colored urine

63
Q

What time frame does myopathy occur when it is drug-induced?

A

6 months

64
Q

What are the most common drugs that cause myopathies?

A

Statins, Fibrates, steroids, antiretrovirals, daptomycin

65
Q

What causes necrotizing myopathy?

A

Statins, fibrates, and alcohol

66
Q

Which statins have a greater risk for myopathy?

A

Simvastatin, Atorvastatin, Lovastatin due to their lipophilic profile

Simvastatin has many interaction to lower its risks

67
Q

(Fenofibrate/Gemfibrozil) has more risk for myopathies

A

Gemfibrozil

68
Q

What causes mitochondrial myopathy?

A

Zidovudine, ipecac

69
Q

What causes inflammatory myopathy?

A

D-penicillamine and PPI

70
Q

What causes painless myopathies?

A

Diuretics, laxatives, and corticosteroids

71
Q

Which electrolyte deficiencies causes myopathies?

A

Low K, Low phosphate, high magnesium

72
Q

Which kind of myopathy may CK not be elevated?

A

Painless myopathy due to corticosteroids

73
Q

Clinical presentation of rhabdomyolysis?

A

Tea colored urine

Weakness

Muscle pain

74
Q

Other labs to check due to rhabdomylosis?

A

Hyperkalemia and hypocalcemia

Treat hypocalcemia if symptomatic

75
Q

Causes of rhabdomylosis?

A

Trauma (crush syndrome), strenuous exercise, fibrates, statins, alcohol, cocaine

76
Q

Rhabdomyolysis management?

A

Fluid resuscitation ASAP initially at 400ml/hr then 2-3ml/kg/hr avoid diuretics

77
Q

What is myasthenia gravis?

A

Neuromuscular junction disorder that displays weakness and fatigue of skeletal muscles caused by AChR antibodies

78
Q

Pyridostigmine MOA and AE?

A

Blocks acetylcholinesterase and increases ACh in synapse

AE = bradycardia, increased salivation, twitching

79
Q

Pyridostigmine pearls?

A

Caution in glaucoma, CV disease or respiratory disease

Works within 15-30 min

80
Q

Prednisone pearls?

A

Used if pt did not meet tx goal after using pyridostigmine

Treat for 1 month then slowly taper from 10mg a month

81
Q

When should immunosuppression be used in MG?

A

If steroid AE develop, is inadequate, sx relapse, or if refused/CI

82
Q

Azathioprine MOA and AE?

A

Blocks purine synthesis

AE = leukopenia, thrombocytopenia, liver issues, increased infection

83
Q

Azathioprine pearls?

A

Monotherapy or with steroid and/or pyridostigmine

Can take up to a year to work

BBW of chronic suppression leading to malignancy

Warning for TPMT deficiency

Avoid allopurinol

84
Q

Cyclosporine MOA and AE?

A

Blocks production/release of IL-2

AE = Liver damage, infection risk, HTN, hirsutism, increased TG

85
Q

Cyclosporine pearls?

A

Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine

May take a few months to work

BBW of increased risk of infection, HTN, malignancy, and nephrotoxicity

Grapefruit juice increases concentration

Therapeutic range 150-200

86
Q

Tacrolimus MOA and AE?

A

Calcineurin inhibitor; blocks T cell activation

AE = HTN, high potassium

87
Q

Tacrolimus pearls?

A

Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine

Takes up to 12 months to work

BBW of risk of infection and malignancy

Therapeutic range 5-15

88
Q

Mycophenolate mofetil MOA and AE?

A

Blocks purine synthesis

HTN/Hypotension, tachycardia, hypercholesterolemia

89
Q

Mycophenolate mofetil pearls?

A

Monotherapy w/ or w/o glucocorticoids and/or pyridostigmine

Takes up to 12 months

BBW of increased risk of infection, lymphoma, skin malignancy, pregnancy loss in first trimester

90
Q

Eculizumab MOA and AE?

A

Binds to complement protein 5

HTN/hypotension, tachycardia, hypokalemia, UTI

91
Q

Eculizumab pearls?

A

For generalized MG in refractory pt

BBW of N. meningitidis (give vaccine 2 weeks prior)

92
Q

Rituximab MOA and AE?

A

Binds to CD20 on B cells

Flushing, night sweats, HTN

93
Q

Rituximab pearls?

A

For severe refractory MG

Considered as an early tx option in those w/ MuSK antibody positive MG who failed initial immunotherapy

BBW of Hep B reactivation

94
Q

What are the sx of Myasthenia crisis and how do you treat it?

A

Sx = difficulty breathing

Tx = plasmapheresis or IVIg

95
Q

When should someone not take plasmapheresis or IVIg?

A

Plasmapheresis = sepsis

IVIg = hypercoagulable state, renal failure

96
Q

What meds can exacerbate MG?

A

BB

ABx

Botulinum toxin

Magnesium

…caines

Penicillamine

Quinine derivates

97
Q

MG presents in whom?

A

Women <40 or Men <50

98
Q

What is GBS? and who does it affect?

A

Immune system attacks PNS particularly the brain and spinal cord; acute inflammatory demyelinating polyneuropathy is the most common form

Affects more men than women and in older adults, but can occur at any age

99
Q

Pathophys of GBS?

A

Damage to myelin sheath of peripheral nerves via MAC attack on Schwann cells

Cause is unknown but most cases occur after acute respiratory or GI infection. Could be from vaccinations too

100
Q

What labs could be collected for GBS?

A

Elevated CSF

Decreased WBC

101
Q

How is GBS diagnosed?

A

Symmetrical weakness, usually starting in legs (sometimes pain, numbness, tingles occur around the weakness time)

102
Q

GBS treatment?

A

Within 2 weeks

Plasmapheresis or IVIg

103
Q

Which vaccines are CI for GBS?

A

Within 6 weeks of GBS = flu and Tdap/Td

IPT: MS (3 decks)

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